Want a baby, discordant couple
Apr 29, 2008
Hi there, hope u can help. I'm a 32yr old lady, HIV+ and my husband is HIV-, we want a baby desperately, what options do we have to conceive except IVF, we cannot afford the cost of insemination. Thanks.
Response from Dr. Frascino
At present in vitro fertilization is the safest way for an HIV-positive woman and HIV-negative man to conceive a child. If that is not available or feasible, other options could be considered. They would include driving your HIV plasma viral load down to undetectable levels with antiretroviral drugs that can safely be used during pregnancy and possibly having your husband use antiretrovirals as well. This would be considered a form of PrEP (Pre-exposure prophylaxis). These techniques have not been completely tested in clinical trials, but there is at least theoretical and suggestive evidence they may significantly decrease HIV-transmission risk while you attempt to conceive "naturally." I would certainly consult an HIV-knowledgeable obstetrician as you begin this undertaking and have him or her confer with your HIV specialist. You should also be advised exactly when during your cycle you are most fertile (likely to conceive) so that your husband can decrease his unprotected exposures while maximizing your chances for pregnancy. I'll reprint some information about magnetic couples and pregnancy below for our readers.
Children and aids (SPERM WASHING) (PREGNANCY) (POSITIVE PREGNANCY) Mar 24, 2008
I was wondering if a man who has AIDs is able to impregnate his wife safely
Response from Dr. Frascino
Yes. A variety of techniques have been developed to significantly reduce the possibility of transmitting HIV to a wife or fetus. These techniques involve sperm washing and in vitro fertilization. See below.
Please help me (PREGNANCY) Feb 23, 2008
I leave in Ethiopia. I am male living with HIV. My CD4 is now 800 and viral load less than 40 in ML. My problem is I have a wife who is HIV negative, who want to have a baby from me only with sexual intercourse know the baby can be safe with proper medicine but I am worrying that my wife will be infected. How much is the risk of transmission from me to her and is their any possible way decrease the risk and make my wife have baby from me. Please help me what I can do? In my country sperm washing cant work. Please, advise me.
Response from Dr. Frascino
Certainly sperm washing and in vitro fertilization would be the safest way for a magnetic couple to conceive. If that is not an option and you are determined to begin a family, I would suggest you work closely with an HIV/AIDS specialist as well as an HIV/AIDS-knowledgeable obstetrician. The risk of HIV transmission can be very significantly reduced if you have had an undetectable HIV plasma viral load on your HIV medications for the past six months. You should also be screened for any other potential STDs before attempting to conceive. In addition you can discuss with your doctors the best time during your wife's monthly cycle to attempt conception. This would hopefully decrease her exposure and allow for the best chance for pregnancy to occur.
Good luck to you both.
What I Can do (SPERM WASHING) (PREGNANCY) Feb 16, 2008
I am male living with HIV. I am takink the ARV therapy before four Years My CD4 is now 896 and undetectable viral load(less than 40 in ML). My problem is I have a wife who is HIV negative, who want to have a baby from me only with sexual intercorse.I know the baby can be safe with proper medicine but I am woring that my wife will be infected . How much is the risk of transmission from me to her and is their any possible way decrease the risk and make my wife have baby from me. Please help me what i can do
Response from Dr. Frascino
I've discussed this topic many times in this forum. See below.
Discordant couple wanting a baby (SPERM WASHING) Jan 29, 2008
Dear Dr. Frascino:
Four months ago my husband tested positive for HIV-1 and started treatment right away. Fortunately for me, I tested negative after two years of unprotected sex and really trying hard for a baby. Now that were finally getting used to these big changes that HIV news brought with it, the baby question came back. Were exploring some avenues for having a baby together in the safest way possible. I love my husband to death but Im EXTREMELY worried about catching the virus even if the chance is close to zero. Recently, as I was searching the internet, I found this article Complete removal of HIV-1 RNA and proviral DNA from semen by the swim-up method: assisted reproduction technique using spermatozoa free from HIV-1 published by the Japanese scientists. Unfortunately, I didnt seem to find any follow up articles on this topic by the same group of scientists. I was wondering:
a.Have you heard about this study? b.Do you know if they made any further progress in Japan? Money is not an issue for us and were willing to travel as far as Japan to have the procedure done if that means no risk for me or my baby. c.Do you think there is any prospect of US adopting that procedure? d.What do you think of the current methods available in the US for HIV discordant couples?
Doctor Frascino, I love you!!! Thank you for being there for all of us!!!
Response from Dr. Frascino
a) Yes, and I posted information about it in the archives. (See below.)
b) I know other centers are using similar swim-up techniques successfully. I'm fairly sure there have been reports from Hôpital Paul de Viguier in Toulouse among others. I don't know where you are writing from, but your husband's HIV specialist should be able to refer you to the best and closest medical center experienced in these procedures.
c and d) Yes, I believe this or similar techniques are being used in the U.S. You can check with some of the resources listed below in Dr. Lee's response from the archives.
Good luck with your upcoming new addition!
sperm washing .... and Bush Jul 24, 2006
I'm part of a magnetic couple here in NYC. What's the latest on my chances to conceive a bambino safely with my HIV positive hubby?
I'm not a Bush fan but don't you think the homeland security department are makng good decisions to keep us safe?
Times Square Sally
Response from Dr. Frascino
Hey Times Square Sally,
I'll post a question from the archives below that addresses this topic.
In addition, there has been a report from Japanese researchers recently describing an improvement in the method of sperm-washing that appears to remove even the theoretical risk of HIV infection for an HIV-negative woman wanting to conceive a child with an HIV-positive guy. The report appeared a few months ago in the medical journal "AIDS." The researchers revised the "swim-up" method of sperm washing and designed an Ultrasensitive HIV RNA/DNA test to confirm that the sperm of all 48 HIV-positive men in the study was completely free of HIV, including the proviral HIV DNA that we had previously theorized could pose a risk for HIV transmission. So this is great news! Your husband's HIV specialist would be able to provide you with a referral to an HIV-knowledgeable OB/GYN specialist to help organize the sperm washing and in vitro fertilization procedures.
Now, turning to the homeland security issue, do you really feel safe with Michael Chertoff in charge??? Yikes!!! Have you seen Chertoff's current list of potential terrorist targets??? Guess which state has the absolute most number of potential terrorist targets in the newly released 2006 National Asset Database, according to the Department of Homeland Security??? Give up? It's Indiana!!!! Yep, Indiana! Indiana clocked in with 8,591 potential terrorist targets!!! My favorite on that list is the Amish Country Popcorn Factory! (Honest! It's really on there!) Now take a look at the number of potential targets in New York State. It registered only 5,687. And what about my state, California, the most populous state in the nation? Well, we only rated 3,212 potential targets.
So, um, Times Square Sally, if you really want the Department of Homeland Security to protect you, you better consider moving to the Amish Country Popcorn Factory in Indiana because guess what?!? Times Square in New York City didn't even make the terrorist target list! Oh yea, that Chertoff is doing a hell of a job.
So bottom line: In vitro fertilization and sperm washing for magnetic couples wanting to conceive is safe! But the United States of America, under Dubya and Chertoff, is anything but safe (unless you happen to like Amish popcorn).
Want to NOT end this...
Jul 1, 2006
Dear Dr Bob,
I posted on June 18 a rather bleak outlook for my newly HIV positive life. I took your advice and now I feel great. I found comfort in reading the 'Just Diagnosed' section of this website.
My psychiatrist hooked me up with a paedeatric oncologist - I think that basically means a doctor who deals with children who have cancer. I was taken through the wards and all of a sudden my problems seemed completely insignificant.
My psychiatrist also hooked me up with a great HIV specialist doc - she really knows her stuff and was really supportive. My initial numbers indicate that I am 'progressing normally'. So far I don't require medicine and she said probably not for a while!!
I found a new employer and even ennrolled in college. My family is taking me on a trip to NYC as well and my girlfriend and I are back to talking.
I have realised that there is still a great deal I want to do with this life like travel, career, charity work, even have a family (my HIV doc says this is possible - though I don't see how if my semen is infected won't my child and / or wife be as well - please explain?).
I now feel as though there is not enough time on the planet rather than before when I dreaded every future moment with anxiety and a 'feel sorry for myself' attitude.
So thank you because you, at least in part, got me motivated enough to start this new 'virally enhanced' life!!!
Peace out - David.
Response from Dr. Frascino
Welcome back! Looks like you not only took my advice, but also that of Patti Labelle! Remember her song "New Attitude?"
"I'm feelin' good from my head to my shoes Know where I'm goin' and I know what to do I tidied up my point of view I got a new attitude Runnin' hot, runnin' cold I was runnin' into overload It was extremes, ex-ex-ex-ex-ex-extreme It took it so high, so low So low, there was nowhere to go Like a dream Somehow the wires uncrossed, the tables were turned Never knew I had such a lesson to learn I'm feelin' good from my head to my shoes . . . ."
And I think there are a lot of ooh, ooh, ooh, oohs in there as well . . . .
At any rate, I'm delighted with your new positive outlook on being positive!
As for the feasibility of your having a family, your HIV doctor is correct. With new sperm washing techniques coupled with in vitro fertilization, there is no reason why you should have to forgo the pleasures of fatherhood! I'll repost a question from the archives that addresses this topic.
Be well. Stay well, David!
HIV+ person wants children Mar 13, 2006
Hey Dr. Bob I have a client who found out recently that his boyfriend is HIV+. He asked me a question about the possibility of his boyfriend having children in the future. I told him that because it would probably be in vitro fertilization and a surrogate mother I couldn't see much risk of the child being +. Then I realized that I didn't really know what I was talking about so I decided to ask you. Can you clear this up for us? Health Educator in DC
Response from Dr. Frascino
Hi DC Health Educator,
The issue of HIV+ men wanting to conceive children safely and decrease the likelihood their mate or offspring will acquire the virus is a complex topic. I'll repeat a question from the archives that summarizes our current recommendations.
HIV + male HIV - female Feb 12, 2006
Dr. I have a question concerning having children. I have asked my HIV specialist and I am getting mixed answers. I am HIV pos and my wife is HIV neg. we really want to have a child, is it really possible to have a child without endangering her life and the child life. We decided against adoption and artificial reproduction (sperm banks). These were options to us. Is it really safe? Please give a yes or no answer if possible. I haven't received an answer.
Response from Dr. Frascino
I'll repost a response form Dr. Sharon Lee below that addresses this problem.
Resources for Positive Men & Negative Women Who Want a Baby Oct 16, 2004 Response from Dr. Lee
Several people have written recently asking for information about sperm washing and their hopes about having a baby when the man is positive and the woman is negative. There are a growing number of places that provide information and that provide these services. Here is a comment and list of general resources:
Studies have suggested that HIV is not present in the sperm themselves but it is in the fluid which surrounds them (Semen). Sperm washing consists of removing the semen (and presumably the HIV) from the sperm and then using the "washed" sperm for insemination. There are currently three ways to attempt pregnancy using washed sperm. A common method used for years is intravaginal insemination, which involves holding a cervical cap full of live sperm near a woman's cervix and allowing them to swim into the uterus. Another is to directly insert the washed sperm into the uterus through a cannula (or plastic tube) placed through the cervix into the uterus. The safest method is in vitro fertilization, which only exposes the woman to fertilized eggs, and not to live sperm cells. In this technique the sperm cells and the egg are brought together in a laboratory and the fertilized eggs are implanted directly into the woman's uterus.
Sperm-washing combined was reported to be the source of one man passing the virus to his partner, though it remains unclear whether her infection was caused by the procedure. (A lawsuit is underway.) Health care professionals willing to undertake the sperm-washing venture are quick to remind their patients that it is only a risk-reduction method, and that no procedure is entirely risk-free. There are several places in the United States that utilize sperm washing. However, due to quite variable policies, you will need to contact fertility specialists in your individual area to find a doctor or to be referred.
1. American Society for Reproductive Medicine. Visit www.asrm.org.
2. Bay Area Perinatal AIDS Center (BAPAC), at the University of California, San Francisco's (UCSF) Positive Health Program in San Francisco General Hospital. Offers pre-conception counseling and infertility work-up to seroconcordant and discordant couples (both partners positive or one partner is positive). Also conducts prenatal care to HIV-positive women. Call (415) 206-8919. Visit http://php.ucsf.edu/bapac.
3. Center for Women's Reproductive Care, at Columbia University in New York City. Conducts IVF for serodiscordant couples. Call (646) 756-8282.
4. Duncan Holly Biomedical. Operates the Special Program of Assisted Reproduction (SPAR), started in 1994 as a support group for couples living with incurable sexually transmitted virus diseases such as HIV. Developed a mail-in product for shipping sperm-washed samples to fertility clinics around the country, as well as an HIV testing kit for sperm that can be mailed to you at home. Complete details and in-depth articles available on its Web site, including the story of Baby Ryan, the first baby conceived through SPAR. Call (781) 665-0750 or (617) 623-7447, or visit www.duncanholly.com/idi/spar/spar_main.html
5. Reproductive Lab Service, 233 East Erie St. Suite 309, Chicago, IL 60611. Call toll-free: (877) REPROLAB (737-7652). Visit www.reprolab.org
6. SMART (Sisterhood Mobilized for AIDS/HIV Research & Treatment), New York City, provides treatment and prevention education and support for women impacted by HIV/AIDS. Call (917) 593-8797, write email@example.com or visit www.smartuniversity.org.
7. "Sperm Washing: Reducing the Risk of Father-to-Mother Transmission." Comprehensive article, although written in 2001. Visit http://hivinsite.ucsf.edu.
8. Women Organized in Response to Life-Threatening Diseases (WORLD), 414 13th Street, 2nd floor, Oakland, CA 94612. Call (510) 986-0340. Visit www.womenhiv.org. Unfortunately, not all copies of their excellent newsletter and articles are available on-line. However, an abbreviated version of their article "Reducing the Risks of Conception: Getting Pregnant When One or Both Partners is HIV positive," is available at www.PositiveWords.com. The article is very easy to understand and extremely detailed.
To each of the couples who are concerned about this issue: our best wishes for wellness for you and your families!
Doc Can I be a daddy??? May 25, 2003
Hi Doctor Bob
I've been reading this board for over 2 months and I'd like to say i think... i mean I know you are one of theeeee smartest and wittiest Docs around to be honest most are quite the zzzzzzzzzzzzzzzz.
Anyhow... is it at all possible for a HIV POZ man to ever become a father without infecting the mother or the baby????
Thanks a billion and keep being YOU.
Response from Dr. Frascino
Hey possible future Dad,
I'm glad you don't find this forum a zzzzzzzzzzzz!
Is it possible for us positoids to be dads without infecting the mom or baby? Yes, it's possible, but it's not completely without risk. It involves a medical technique called "sperm washing." Now before you start thinking about having sex in your Maytag, let me explain. Using various techniques, sperm can be separated from the other fluids in cum. These other fluids carry the vast majority of HIV. The washed sperm is then used for artificial insemination or in-vitro fertilization. This technique drastically reduces the risk of HIV transmission. There are a variety of medical centers around the world studying this technique (Milan, Italy, for example). In the US, there are programs at Tufts University/New England Medical Center in Boston. Although it's a bit dated, check out the article in the Washington Post called "Seeking a Safe Path Toward Fatherhood." It can be found at http://washingtonpost.com/wp-dyn/articles/A99181-1999Apr18.html
Good luck! If it's a boy, can you name him Dr. Bob?
Response from Dr. Frascino
For additional recent information see below.
European Alternative to Sperm Washing Feb 3, 2008
Hi Dr. Frascino:
There have been so many sperm washing questions recently and since the fertility rates go down so much and it costs so much per try, I was wondering what you thought of the study below by Vernazza: and also this study: Safety and efficacy of sperm washing in HIV-1-serodiscordant couples where the male is infected: results from the European CREAThE network. Louis Bujan, Lital Hollander, Mathieu Coudert, Carole Gilling-Smith, Alexandra Vucetich, Juliette Guibert, Pietro Vernazza, Jeanine Ohl, Michael Weigel, Yvon Englert, Augusto E. Semprini, for the CREAThE network. AIDS. September 2007;21(14):1909-1914
Pietro Vernazza, a physician at the Cantonal Hospital in St. Gallen, Switzerland, is going to talk a little bit about his poster, which is very interesting. Dr. Vernazza, could you tell me a little bit about why you decided to do this poster?
Yes. We have been involved in the past 10 years in insemination with processed semen from [serodiscordant] couples who wanted to conceive a child. Now, we also have studied, together with colleagues in the United States, the risk of transmission as a function of HIV viral load and semen. What I realized from 2000 onwards: All these couples that came in for treatment were very select couples, where the male [HIV-positive] partner was on a fully suppressive treatment. When we measured HIV in their semen, it was not existent at all. We couldn't find it. So I knew the risk of a transmission is very, very low.
Now, when we sent them, then, to the infertility clinic, this is a procedure that is quite time consuming. It's also costly. I started to ask myself whether this process is actually ethically correct. Then, in addition, I talked to Enrico Semprini, who was the first who started with the insemination [click here to view some of Semprini's publications].
Is this in Italy?
This is in Milan. And he followed ... About one third of the women who came for the first consultation would never show up for an insemination. And within Europe, all the centers have about one third no-shows, [these are people] who just don't follow up. Semprini followed up with them. And among the 500 couples, 250 are parents now.
So we realized we are giving a treatment for two thirds of the couples. About one third, or 40%, will get a baby. But the rest will do it [have unprotected sexual intercourse in order to conceive] by themselves.
We were sort of accepting that a major group of these clients, and all those outside of the program, were taking the risk and having unprotected sex. So we thought: It's okay. The risk is very, very low. It's probably in the range of one in 100,000, or one in one million. That's about the risk that you take when you mount an airplane.
We thought: Could we help these couples to reduce this, even very, very little risk? It's like wearing a seatbelt. We give them an additional safety. The additional safety is that we teach them just to have sex at the right time, when ovulation is happening (with a urine test).
Second thing: We make sure they don't have some asymptomatic chlamydia or other sexually transmitted diseases, because that increases the risk of transmission.
Then we make sure they are really stable, under a suppressive HAART. And the fourth point, which is probably the most important: We give a pre-exposure prophylaxis to the woman prior to the sexual contact -- the unprotected sexual act to conceive the baby.
We give them two doses of tenofovir [brand name: Viread; also known as TDF] at the time. When the urine test is positive [for ovulation], the next day, then the same evening, they have sex. Interestingly, the pregnancy rate in these couples is exceedingly high. After three unprotected acts, it's more than 50%. And it goes to a maximum, to a plateau, at around 70 to 75%.
I felt that is very interesting. It's certainly better than with the insemination practice, where we reach 40%. So I felt we should let people know about this experience.
Why did you choose tenofovir when the latest studies with chimpanzees showed FTC [generic name: emtricitabine; brand name: Emtriva] and tenofovir was better, or seemed to be a better prevention? My second question is: Why two doses, and not more, for a week? I know there are two days of ovulation, but it gives them more freedom.
Tenofovir has the advantage of a very, very long intracellular half-life that is about a week. So it is taken up over one or two days, and then it remains there at the place of action within the cells for a week. So that covers the risk period completely.
The question I have been asked at the poster discussion is: Why do you give it at all, since the risk is so low? I think that is probably the more relevant question. I think we give it to give a sort of psychological, additional argument, but I agree it's really a theoretically miniscule risk. And it's probably psychological. That would be the reason why I wouldn't go directly to a combination with FTC. But if you want to be more safe, safer than safe, that's fine.
I see. Because in actuality, we don't know whether the tenofovir did help at all in these couples. There's no way of teasing that out.
Of course. Right. We'll never find out.
How many couples did you do this with?
The ones that I recorded here [in this poster] are 22 couples. I also have, now, a collaboration with other clinics in Austria and Munich and in London. They are reporting that we're trying to get together a group of 35 or 40 couples. But it will never prove that there is no risk, because to prove that there is no risk is almost impossible, since we don't see any transmission from individuals with fully suppressed virus to the steady partner. There has been not a single case report worldwide.
But there haven't been any studies, so you can't ...
That's right. We know in the Swiss HIV cohort that approximately 150 to 200 [serodiscordant] couples always have unprotected sex, with fully suppressed virus, and they don't transmit.
In the Swiss cohort.
Yes. I'm sure it's the case with many, many other people. They just have sex. We see many new cases of HIV infection, but none of these new cases are associated with a sexual exposure to a partner on HAART with fully suppressed HIV.
Can you describe some of the illustrations in your poster?
Sperm washing. Reprinted with permission from Pietro Vernazza, M.D., et al. The first illustration shows a little bit of the technique that was developed by Semprini, where there is a two-step technique with a density gradient, where the larger cells, where the lymphocytes are, remain in the upper gradient of the centrifugation and then you collect the motile sperm in the pellet and do a second procedure, where you have a swim-up, where the sperm swim against gravity. And then you remove the upper layer, and that is used for the procedure.
Now, through this procedure you get about 1% of the motile sperm, which also explains a little bit why this method doesn't work as well as natural conception. There are also other reasons.
Pregnancy rates with natural conception. Reprinted with permission from Pietro Vernazza, M.D., et al. Right. Is this what we call sperm washing?
That is sperm washing. In the other graph, I show the number of cycles, and the number of couples. All of the couples started with the first cycle, and 20% of the women got pregnant after one exposure or sexual contact. Then after three [cycles] it's 50%, and it mounts to the plateau of about 70 to 75%. Then even after repeated exposures, you see that these couples very rarely get pregnant. It would mean, probably, that these [couples] have other fertility issues. That also needs to be addressed. I think it's important. All the fertility clinics in Europe that have now gained experience with HIV-positive individuals, they actually can also help them [these infertile couples]. I think there is still a role for fertility clinics to teach HIV-discordant couples. But for the majority of couples who just want to conceive a child, the natural way is much simpler.
A question related to this concerns stigma in Europe. I know in the United States a lot of fertility clinics do not want to publicly acknowledge that they help discordant couples. Is this similar in Europe, or is it more open?
I think it's more open, but there is still this stigma around, and there are still some people who think HIV-positive people, or discordant couples, should not have a child. It's sort of a belief ... or, I don't know ... it may also have to do with punishment. They are responsible for their disease, and they should get punished. It's not the way we think about people who smoke. It's very special for HIV. I think we should try to work against this stigmatization.
I think you're definitely helping with this study, and with explaining how couples do not, necessarily, need the help of fertility clinics to have a baby.
One interesting experience I had during the interviews with the couples: When I asked the couples, "What do you think is the risk of transmission when you have sex tonight?" Their estimate was in the range between 5 and 100%, a little bit higher for the women than for the men. So we haven't really properly informed these couples about the very, very low risk.
Of unprotected sex when one partner who is HIV positive is undetectable.
Exactly. Exactly. They still keep this high risk in their brain, and we haven't really openly talked about the changes in the risk of transmission, which we obviously observe. I think it wasn't a favor to them, because we sent them to the infertility clinics. They had to go through all this trouble. But on the other hand, we know it's not necessary, but we don't tell them. So that, during these interviews, causes a lot of questions, like, "Why I haven't I been told?" It also helps when I can reassure the couple that the question of sexual transmission risk is something that I have been involved with for the past 15 years. I have studied that and done research on that. Otherwise it would probably be a little bit difficult.
But within a few years, I'm sure that knowledge will disseminate, and it will change the habit of everybody.
So what's the reluctance, do you think? In the United States HIV specialists feel reluctant to say that. I have heard them say, "Well, I know the risk is minimal, but I ..." Because I guess they fear being responsible if a transmission occurs. Also, I guess, the second issue is: What if the positive partner becomes detectable? If I'm negative and my partner is positive, and even though he was undetectable the last time he went to the doctor, there is a possibility that he was not adherent and there was some viral breakthrough, so that he becomes detectable. But I believe he's still undetectable. And he doesn't have to go to the doctor for another month.
I think that's a very good point, and that's why I think this discussion about risk and behavior -- how do we make decisions about our sexual life -- is something that belongs in a steady partnership. The program that I'm talking about here is for steady partnerships. It's not about just in general. If I'm living with a partner and she takes drugs for HIV, I know exactly her adherence. I know exactly her virus. I have been talking with her doctor and herself.
So that is a little bit different situation than having sex with a partner who just tells me, "I'm suppressed." So I think it would be smart to restrict unprotected intercourse to couples where the partners know each other very well. I think that's important.
Click here to view Dr. Vernazza's study abstract.
Click here to view the slides from Dr. Vernazza's presentation.
Response from Dr. Frascino
I believe this is very encouraging data, but that the conclusions are premature. I certainly hope the follow-up studies confirm the preliminary results. That would truly be a wonderful advance for magnetic couples wishing to conceive. This report is generating considerable discussion. Stay tuned to The Body as the story evolves.
By Vaughn Taylor and Hanna Tessema
Many HIV-positive women are reluctant to become pregnant because they fear they will pass the virus to their fetuses or that they will become too sick or disabled to care and provide for their children properly. But with counseling and guidance, along with comprehensive healthcare and treatment, many HIV-positive women can have healthy, HIV-negative children.
The key to a successful pregnancy is the health of the mother-to-be. The HIV-positive woman who is pregnant -- or is considering having children -- has an additional reason to take care of herself. Living well with HIV isn't just about antiretrovirals -- it's also about adequate nutrition, quitting smoking, getting enough exercise, and not using recreational drugs (especially those that involve needles). These recommendations will become even more vital during pregnancy, and will be joined by others -- avoiding alcohol and caffeine, for example. The aim is a healthy pregnancy, an HIV-negative baby, and a long, healthy life as a caring mother.
The prospective mother needs to learn everything she can about risks to the fetus during pregnancy and to the baby after delivery. She needs to discuss her options with both her HIV specialist and her obstetrician (and later her baby's pediatrician), in order to determine the choices that are best for her. This article will explore some of those options.
The Importance of Prenatal Care and Counseling Researchers are not sure exactly when HIV is transmitted during pregnancy. While some fetuses can be infected with HIV while developing inside their mothers' uteruses (wombs), the vast majority of infections occur during labor (the time of delivery) or after the baby is born and is breastfed by an HIV-infected mother.
Ideally, preparation for reducing risks to mother and child begins before conception, when the woman and her partner are deciding if, when, and how to have a baby. Without treatment, there is a 25% to 30% chance of an HIV-positive woman passing the virus to her child -- so-called "vertical transmission." Risk of mother-to-child transmission is generally dependent on the pregnant woman's viral load -- the higher the amount of virus during pregnancy and delivery, the greater the higher the chance of transmitting the virus to her baby.
Throughout pregnancy, a developing fetus has its own blood supply. In other words, the developing fetus generally does not come into contact with the blood of the mother. This helps protect the fetus from infections, such as HIV, in the mother's blood. Developing fetuses do, however, receive nutrients and various proteins, such as immune system antibodies, from their mothers. While a mother's HIV may not enter the fetus, her antibodies to the virus will. These antibodies cannot harm the fetus, but will cause the baby to test "positive" to an HIV antibody test at birth.
At the time of birth (labor), a baby often comes into contact with his or her mother's blood. If the mother's blood enters the baby's body, HIV can be transmitted. But with good prenatal care and antiretroviral treatment, the risk of transmission can be reduced to less than 2%.
Sperm Washing Sperm washing is a process that was developed to reduce risk of transmission from an HIV-positive man to his HIV-negative partner, and subsequently to the fetus, while enabling them to conceive a child. If both partners are positive, sperm washing also reduces the risk of cross-infection with a different strain of HIV.
HIV is carried primarily in the seminal fluid rather than in the sperm itself. Sperm washing involves separating the sperm from the seminal fluid, then using it to impregnate the woman when she is ovulating and most likely to become pregnant, or to fertilize her egg through in vitro fertilization.
Integrated Pregnancy Care A comprehensive approach to care is the most effective way for a pregnant woman with HIV infection to have a healthy pregnancy and delivery. While an obstetrician and an HIV specialist are safely and effectively managing the woman's pregnancy, she should also be provided with professional support to help manage psychological, social, and economic challenges should they arise. This might include assistance from a social services agency to help her with counseling, housing, food, and childcare needs, both during pregnancy and after delivery.
Professional counseling before pregnancy can also be extremely helpful. Working closely with her healthcare provider, an HIV-positive women and her partner can learn a great deal about the risks and benefits associated with pregnancy, including treatment options, and different ways of achieving conception.
Antiretroviral Therapy Women who are HIV positive can drastically reduce the risk of transmitting HIV to their babies with the use of antiretroviral drug treatment during pregnancy and at the time of delivery. Deciding when to begin antiretroviral therapy during pregnancy, however -- if it's not already being taken -- and which medications to use can be confusing.
Working with a healthcare provider, HIV-positive women can make important perinatal treatment decisions that best suit their individual needs, while at the same time following state-of-the-art recommendations from the U.S. Department of Health and Human Services (DHHS), the federal agency responsible for setting healthcare policies in the United States. The most recent version of the agency's guidelines, entitled Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV-1 Transmission in the United States, was published on November 2, 2007.
When to Use Treatment During Pregnancy Generally speaking, if an HIV-positive woman requires treatment to protect her own health -- if her CD4 cell count is below 350, for example -- she should not be denied therapy, regardless of whether she is pregnant or plans to become pregnant.
There are lingering questions about the safety of antiretrovirals when used during the first three months (first trimester) of pregnancy, when a developing fetus is believed to be most susceptible to drug toxicity. According to the DHHS, antiretrovirals can be avoided during this three-month period provided the woman does not require treatment to maintain her own health. Otherwise, HIV treatment should be continued throughout pregnancy.
HIV-positive pregnant women who do not require antiretroviral therapy to maintain their own health may be able to stop treatment after giving birth -- a decision that should only be made in consultation with her healthcare team.
Which HIV Drugs to Use During Pregnancy As for specific HIV medications, the DHHS guidelines spell out a number of important considerations that HIV-positive pregnant women and their healthcare providers should be aware of.
First, the nucleoside reverse transcriptase inhibitor (NRTI) Retrovir (zidovudine) has been studied extensively in HIV-positive pregnant women and has been shown to be safe and effective at reducing the transmission of HIV from mother to fetus. In turn, it is almost always recommended as a treatment component during pregnancy and delivery (and given to the infant after birth), even when the woman has HIV that is resistant to it.
The non-nucleoside reverse transcriptase inhibitor (NNRTI) efavirenz, found in Sustiva and Atripla, should not be used by pregnant women and only cautiously by women who might become pregnant. Because efavirenz may cause birth defects if taken during the first trimester -- the first three months of pregnancy -- it is recommended that HIV-positive women have a pregnancy test before starting efavirenz and use adequate birth control while using the drug.
The NNRTI Viramune (nevirapine) has been shown to reduce the risk of mother-to-child HIV transmission, but it is recommended only for women with CD4 counts below 250 cells. There is a higher risk of serious allergic reactions, including liver damage, occurring in women who start Viramune with CD4s higher than 250.
The protease inhibitor Viracept (nelfinavir) should also be avoided during pregnancy, until further notice. In September 2007, Pfizer reported the discovery of a manufacturing impurity, ethyl methanesulfonate (EMS), in U.S. batches of Viracept. As EMS has been found to be cancerous and capable of causing birth defects in animals, the U.S. Food and Drug Administration (FDA) recommends avoiding Viracept during pregnancy until Pfizer has found a way to remove EMS from the drug.
It is also a good idea to switch off medications known to cause serious side effects in women during pregnancy. For example, the FDA has warned that HIV-positive pregnant women should not take Zerit (stavudine) and Videx (didanosine) at the same time. Some pregnant women who took these drugs together developed lactic acidosis -- a serious and sometimes fatal buildup of lactic acid in the blood, which can cause fatigue, nausea/vomiting, painful inflammation of the pancreas, and liver damage.
Other Considerations During Pregnancy It is important to remember that pregnancy-related complications typically seen in women who are not living with HIV, such as hypertensive disorders, ectopic pregnancy, gestational diabetes, psychiatric illness, preterm delivery, and STDs, also can occur in pregnant women living with HIV.
Finally, there are some aspects of typical prenatal care that might not be suitable for HIV-positive pregnant women. For example, amniocentesis, used to test for genetic defects in the baby, is done with a needle that passes through the mother's abdomen and into the womb. While this test may be necessary to look for any genetic problems that a developing baby may have, it can also increase the risk of transmitting HIV. Before undergoing amniocentesis, HIV-positive pregnant women may want to discuss its benefits and risks with their healthcare provider.
Labor and Delivery Labor and delivery are believed to be riskiest time for HIV transmission during pregnancy, as babies are most likely to be exposed to their mother's blood during the birthing process. To reduce this risk, healthcare providers should avoid performing amniotomies -- intentionally rupturing the amniotic sac to "make the water break" and induce labor. The risk of transmission increases by 2% for every hour after membranes have been ruptured.
An episiotomy -- a surgical incision through the perineum made to enlarge the vagina and assist childbirth -- can also expose the infant to the mother's blood and increase the danger of transmission. What's more, the use of birthing instruments and common procedures, such as forceps/vacuum extractors, scalp electrodes, scalp blood sampling, and internal fetal monitoring, can cause small tears in the baby's skin and increase the risk of transmission further.
Cesarean Sections vs. Vaginal Delivery A Cesarean section -- also referred to as C-section -- is delivery via a surgical incision through the maternal abdomen and uterus. It is one of the oldest documented surgical procedures. A C-section is performed when a vaginal birth is not possible or is not safe for the mother or child. Because of a variety of medical and social factors, C-sections have become fairly common -- about 26% of all births in the United States in 2002 were C-sections.
C-sections can greatly reduce an HIV-positive woman's risk of passing along the virus to her baby at the time of birth, as they greatly reduce the amount of time a baby remains in contact with his or her mother's blood and other fluids during delivery. It is still not known, however, if C-sections are any more effective than if the woman takes a powerful combination of antiretroviral drugs throughout her pregnancy. It is also not known if a woman who takes a powerful HIV drug combination and has a C-section has a lower chance of passing along the virus to her baby than a woman who takes HIV drugs and has a vaginal delivery.
Some experts do not like the idea of C-sections used solely to reduce the risk of mother-to-child HIV transmission. Because C-sections are a type of surgery, there are risks of infection and other complications. In fact, HIV-positive women may be at a higher risk for infection while undergoing C-section delivery or other complications than HIV-negative women. It is also important to remember that combination HIV treatment might do a better job of stopping transmission than a C-section. According to some studies, in HIV-positive pregnant women who have an undetectable viral load at the time of birth, the risk of delivering a baby infected with the virus is less than 2%, even with vaginal delivery. It is not known if C-sections reduce this risk further.
In its perinatal treatment guidelines, the DHHS says that C-sections are only recommended for the purpose of reducing the risk of mother-to-child HIV transmission when the mother's viral load is higher than 1,000 at week 36 of the pregnancy. A woman with a viral load below 1,000 should be counseled that her risk of transmitting the virus to her baby is low and that there is currently no information concluding that performing a scheduled cesarean section will lower her risk further. DHHS also says that, if C-section delivery is chosen, it should be scheduled for week 38 of the pregnancy.
Postnatal Treatment The months following delivery of a baby by an HIV-positive woman are also crucial to keeping the risk of vertical transmission to a minimum.
After the baby is born, the doctor will likely advise that he or she take anti-HIV drugs for four to six weeks, usually a liquid form of Retrovir taken two or four times a day, possibly in combination with other HIV medications. Studies suggest that the use of antiretroviral treatment during the first few weeks of life plays a role in further lowering the risk of HIV infection in a newborn baby. No significant side effects of Retrovir have been observed, other than a mild anemia in some infants that cleared up when the drug was stopped. Follow-up studies show that the HIV-negative treated babies continued to develop normally.
Learning the Baby's HIV Status An HIV-positive new mother usually wants to know right away whether her baby is infected. It can take several months to learn definitively the HIV status of a newborn. Moreover, it is important to keep in mind what an HIV test is. The standard test looks for antibodies to HIV; it does not look for the virus itself. Because a fetus is exposed to the mother's HIV antibodies, the baby will automatically test "positive" after birth. These antibodies can remain in the baby's body for more than 18 months after birth.
Most hospitals now conduct nucleic acid testing, which looks for the virus itself, on babies born to HIV-infected women. This test can be performed within a few days after delivery and looks for HIV itself in a blood sample collected from the baby. If the test is negative, it should be repeated within a few months after the birth.
Breastfeeding Breast milk also carries HIV, and breastfeeding adds considerable risk of transmission. As with transmission via blood, there's some indication that risk increases along with viral load (the amount of HIV in the mother's blood). So far, research shows that the risk of breast milk transmission is highest in the first six months of life. There's no threshold, however, or point beyond which it becomes absolutely safe to breastfeed.
Wherever clean water and formula are available, it is recommended that HIV-positive women exclusively formula feed their infants.
In recent years, studies have also looked at breast milk pasteurization, a procedure that allows women to express their breast milk and treat it themselves so that it becomes safe for their infants to drink. Right now, these studies have been done in resource-poor settings; your doctor may have more information about this strategy.
Vaughn Taylor is Manager and Hanna Tessema Associate Manager of ACRIA's Older Adults Training and Technical Assistance Program.
This article was provided by AIDS Community Research Initiative of America. It is a part of the publication ACRIA Update.
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